Monday, April 25, 2011


CONNECTIVE TISSUE is the supporting structure in a joint including tendons, muscles, ligaments and, in some cases, the cushioning cartilage between the joint. In a person’s life, 100% of us sustain an injury to these tissues. This result in strains and sprains with or without fractures of the involved joint. A strain is an injury to a muscle and/or its tendon, the tissue that connects muscles to bones. A sprain is an injury to a ligament, the tough, fibrous tissue that connects bones to other bone. These injuries involve a stretching or a tearing of the tissue and produces inflammation. “Tendinosis”, a better term than tendonitis, on the other hand refers to non-inflammatory injury to these tissues at the cellular level. These conditions are caused by damage to collagen, cells, and some due to the vascular components of the structure, which ultimately could lead to rupture by a different mechanism than acute trauma. These “tendinopathies” may be caused by both extrinsic and intrinsic factors including age, genetics (Ehlers Danlos Syndrome), body weight and nutrition. The extrinsic factors are often related to sports and include excessive forces or loading, poor training techniques, environmental conditions, posture and gait. Depending on the severity of the injury, the damage may be a simple overstretch of the tissue, or it can result in a partial or complete tear!

A sprain or strain typically occurs when people fall and land on an outstretched arm, slide into base, land on the side of their foot, or twist a knee with the foot planted firmly on the ground. This results in a overstretch or tear of the tendon/muscle or ligament(s) supporting that joint. Strains can be acute or chronic. An acute strain is caused by trauma or an injury such as a blow to the body. Improperly lifting heavy objects or overstressing the muscles can also cause it. Chronic strains are usually the result of overuse injury (prolonged, repetitive movement of the muscles and tendons).

Although all joints can potentially be sprained or strained, the most common is the ankle the second is the shoulder, and the third, the ankle counterpart in the upper extremity, the wrist.
The ankle is most commonly severely injured in professional, recreational sports and even in ordinary activities like walking. Most ankle sprains happen when the foot abruptly turns inward (inversion) or outward (aversion) as athletes run, turn, fall, or land after a jump. One or more of the lateral or medial ligaments are injured but a tendon and its attached muscle can also be hurt.
The usual symptom of a muscle/tendon strain or a ligament sprain is pain, and the signs are swelling, bruising, and the loss of function (the inability to move and use the joint). Sometimes people feel a pop or tear when the injury happens. The signs and symptoms can vary in intensity, depending on the severity of the sprain.

The severity is graded one, two and three. A grade I (mild) is overstretching or slight tearing of the tissues with no joint instability. A person usually experiences minimal pain, swelling, and little or no loss of function. Bruising is absent or slight, and the person is usually able to put weight on the affected joint. A grade II (moderate) causes partial tearing and is characterized by bruising, moderate pain, and swelling. There is some difficulty putting weight on the affected joint and there is some loss of function. An x-ray or rarely an MRI may be needed to document both the diagnoses and stage. A grade III (severe) results in a complete tear or rupture. Pain, swelling, and bruising are significant, and the patient is unable to put weight on the joint. An x-ray is usually taken to rule out a fracture in the adjacent bone. Type III injury often requires immobilization and possibly surgery. It can also increase the risk of the person having future problems in that area.

Contact sports such as soccer, football, hockey, boxing, and wrestling put people at risk for strains. Gymnastics, tennis, rowing, golf, and other sports that require extensive gripping can increase the risk of hand and forearm strains. Elbow strains a type of repetitive syndrome occur in people who participate in racket sports, throwing, contact sports and work. The latter in occupations such as carpentry that requires hammering. Two Common Elbow Strains are Tennis Elbow (lateral epicondylitis) and Golfer’s Elbow (medial epicondylitis).

The healing time varies with the severity of the injury with mild and only a few fibers have been damaged. Healing occurs within two to three weeks. With moderate injury with more extensive damage to the fibers, but the tissues is not completely ruptured. Healing occurs within three to six weeks. But with a severe injury and a complete severing of the bundle. It is another story. This may require surgical repair of the tissue and the healing period can be up to a year!

Tendons, muscles, and ligaments are capable of healing and recovering from injuries in a process that is controlled by the fibers and their surrounding extracellular matrix. However, the healed tendons and ligaments never regain the same mechanical properties as before the injury. Muscle have a good blood supply, which is impart why they are red heal far faster and better than the anemic white tendons and ligaments. The three main stages of healing are inflammation, repair ( proliferation), and remodeling. Nature does a good job with these processes, but doctors can help patients to augment the rapidity of healing.

Most current treatments for the joint supportive structures are neither evidence-
based or effective. Typically Doctors recommend RICE- Rest, Ice, Compression, and
Elevation. They also give anti-inflammatory such as Ibuprofen which may help with
the pain, but delays the healing in that inflammation itself as noted above is part of
the healing process. In some cases immobilization may be helpful, but in others in
which there is no associated fracture, it delays healing in that it decreases the
natural growth factors that are stimulated with joint movement.

Molecular processes underlying joint structure healing are now being elucidated.
Metalloproteinase enzymes are thought to have a key role in the regulation of the activity of tendon cells and matrix remodeling in both normal and pathologic structures. The potential roles of neuropeptides, inflammatory mediators and mechanical strain (either too much or too little) acting on the resident tenocytes are noted to stimulate the intrinsic healing G-Proteins. Excessive or inappropriate activity of destructive matrix-degrading enzymes might be a novel therapeutic target for tendinopathy. Tenocytes in the tendon actively synthesize components as well as enzymes such as matrix metalloproteinases . Bone morphogenetic proteins (BMPs) can induce bone and cartilage formation as well as tissue differentiation, and BMP-12 specifically has been shown to influence formation and differentiation of tendon tissue and to promote fibrogenesis.

Now avant guarde physicians give Enzymes such as Bromelain and Papain early in acute trauma, don’t use inflammatory suppressants but pro-inflamants (prolotherapy), early or no immobilization, even irritating the structures such as the “aggravating technique” in tennis elbow, and a cellular level, nitroglycerin (NTG)!

The rational that NTG could be used pharmacologically to accelerate repair in injured tendons has been well documented. Gambito E, "Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis" (Arch. Phys. Med. Rehabil. 2010;91:1291-305). In a more recent study from the University of Toronto (JAMA.Feb 23;2011) Jamal found that nitroglycerin ointment increased both bone density and strength in postmenopausal women. The mechanism for tendon and bone repair is speculated to be enhancement of a group of connective tissue enzymes, the metalloproteinases and a cytokine, specifically Il-17.

Bearing the above in mind, I have used NTG ointment on over thirty patients with tendon/cartilage injuries to include rotator cuff, hip, knee, and neck with good results. In the past, I have also used a topical muscle relaxant (Flexeral), an antinflamatory (Ketoprofen), an analgesic (Lidocaine) separately or together in an absorptive matrix. I have since added them to NTG to augment the earlier healing liniment and have had even better results. This combination of salubriants must be obtained at a compounding pharmacy. Many medical insurances do pay for these prescription. For more information call Chris Schiller at Economy Pharmacy (918-994-5804).

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